Helmet Removal

Updated: Aug 19, 2021

Author: James Cipolla, MD; Chief Editor: Jonathan P Miller, MD

Overview

Background

With each passing year, more individuals are playing contact sports and riding motorcycles. Therefore, healthcare workers involved in emergency care should be proficient in the procedure of helmet removal.[1, 2] Helmet removal, which requires minimal training, is a safe and quick procedure that gives providers access to a patient's airway and allows them to stabilize the patient's head and neck.[3, 4, 5, 6, 7]

Indications

The indications for hospital helmet removal are as follows:

Suspected cervical spine injury
Suspected head injury
Inability to securely immobilize the neck prior to transport to another healthcare facility[8]

The following prehospital recommendations for helmet removal are based on the Inter-Association Task Force's Prehospital Care of the Spine-Injured Athlete:[9]

If the helmet and chin strap fail to hold the head securely[10]
If the helmet and chin strap design prevent adequate airway control, even after facemask removal
If the facemask cannot be removed
If the helmet prevents adequate proper immobilization for transport

Contraindications

The major contraindications to helmet removal are paresthesia or neck pain during the removal procedure. Paresthesia suggests worsening stretch or pressure on nerve endings as they exit the spinal column.

Healthcare providers with minimal knowledge of helmet removal should use caution if attempting to remove a helmet.

Best Practices

A cordless screwdriver is the most efficient tool for removing the screws attaching the facemask to the helmet because it can reduce the time needed for screw removal and help reduce spinal motion.

If the airway is unstable, facemask removal is all that is necessary to intubate the patient; the entire football helmet does not need to be removed for intubation. According to one study, face mask removal for the potential spine-injured American football player is safer than helmet removal for emergent airway access.[24] Face mask removal results in less motion in all three planes (sagittal, frontal, transverse), requires less completion time, and is easier to perform.

Fullface motorcycle helmets should be removed in the prehospital setting for the following reasons:

They can increase forward flexion of the neck when the patient is placed on a backboard.
The airway cannot be observed with a full helmet in place.

Periprocedural Care

Equipment

Providers: At least 2 providers (3-4 is ideal) should be present.

Facemask removal: Studies have been performed to determine the ideal tool to remove the facemask in prehospital and hospital settings.[11] The findings suggest that a cordless screwdriver is the superior tool to remove the screws securing the facemask.[12] However, a manual screwdriver can also be used.

Screwdrivers have been shown to minimize neck motion more than pipe cutters, anvil pruners, facemask extractors, or Trainer’s Angels. These 4 tools do reduce the time needed to remove a facemask; unfortunately, they also increase the amount of motion of the cervical spine.

Helmet removal: A pair of scissors is also necessary for helmet removal.[13] Scissors should be used to cut clothing and the laces holding the shoulder pads together, if present.[14, 15] Exposure is one of the basic tenets of trauma resuscitation.

Patient Preparation

Anesthesia

No anesthesia is needed for helmet removal.

If airway instability occurs, rapid sequence intubation should be employed to secure the airway. For more information, see Tracheal Intubation, Rapid Sequence Intubation and Tracheal Intubation, Medications.

Positioning

The patient should be placed supine on a long cervical immobilization board if he or she is not already on one.

Minimization of cervical spine motion should be maintained prior to the initiation of helmet removal.[16]

Monitoring & Follow-up

Helmet removal, when performed properly, does not carry inherent risks.

The major complication of helmet removal is worsening an extant cervical spine injury.

Technique

Approach Considerations

The first provider should position himself at the head of the bed and immobilize the cervical spine by placing both hands on the ear holes of the helmets and placing the fingers on the patient’s mandibles bilaterally.[17]

The second provider should then cut the chin strap.

Once the chin strap has been cut, the second provider should take over the job of inline stabilization by placing one hand on the patient’s occiput and another hand on the patient’s chin.[18]

The first provider should then use a screwdriver (manual or cordless) to remove the screws securing the facemask to the helmet. This allows the facemask to be lifted up and out of the way, which opens access to the airway.

If the patient is wearing shoulder pads, a third provider should cut the laces on the anterior portion of the shoulder pads while the first provider is removing the facemask screws. These laces are located superficial to the sternum.[19]

Once the first provider has finished removing all 4 screws, the first and third providers should simultaneously remove the helmet and shoulder pads (if present).

The actual process of removing the helmet requires the first provider to pull the ear holes away from patient’s head.
During this maneuver, the second provider prevents the neck from hyperextending and the head from falling onto the bed.[20, 21]
If shoulder pads are being removed, a third provider should place his hands underneath the patient's shoulders, since the shoulders can drop suddenly, causing extreme flexion of the neck. One recent cadaveric study concluded that this elevated torso technique can minimize cervical spine motion during shoulder pad removal.[22] Another cadaveric study noted that motion was produced during all 3 studied techniques (full body levitation, upper torso tilt, and log roll) and that a single technique could not be deemed better except on a case-by-case basis.[23]
If a fourth provider is available, he may help stabilize the head during the helmet removal process to help prevent overextension of the head onto the bed.

Once the helmet and shoulder pads are removed, the first provider should place a cushion under the patient’s head.

Once the cushion is placed, the first provider should resume maintaining inline stabilization. The second provider, meanwhile, places a rigid cervical collar on the patient.

Once the rigid collar has been applied, the patient can be rolled and the backboard can be removed. Helmet removal is shown in the image below.

Helmet removal.

Author

James Cipolla, MD Attending Surgeon, Department of Traumatology and Critical Care, Program Director, Surgical Critical Care Fellowship, St Luke's University Hospital; Associate Professor of Surgery, Temple University School of Medicine; Assistant Clinical Professor of Surgery, University of Pennsylvania School of Medicine

James Cipolla, MD is a member of the following medical societies: American College of Surgeons, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Ankit Shah, MD Attending Physician, Department of Emergency Medicine, Reading Hospital and Medical Center

Ankit Shah, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, European Society of Intensive Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery, Director of Epilepsy Surgery, Attending Neurosurgeon, University Hospitals Cleveland Medical Center; Director, Functional and Restorative Neurosurgery Center, UH Cleveland Medical Center Neurological Institute; Associate Professor of Neurosurgery, Fellowship Director, Functional and Stereotactic Neurosurgery, Associate Residency Program Director, Department of Neurosurgery, Surgical Director, Neuromodulation Center, Case Western Reserve University School of Medicine

Jonathan P Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Epilepsy Society, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Neuromodulation Society, North American Neuromodulation Society, Ohio State Neurosurgical Society, Society of Neurological Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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